Associations of clinical stroke misclassification ('clinical-imaging dissociation') in acute ischemic stroke

Cerebrovasc Dis. 2010;29(4):395-402. doi: 10.1159/000286342. Epub 2010 Feb 19.


Background: Up to 20% of lacunar infarcts are clinically misdiagnosed as cortical infarcts and vice versa. The reasons for this discrepancy are unclear. We assessed clinical and imaging features which might explain this 'clinical-imaging dissociation' (C-ID).

Methods: Patients with an acute stroke syndrome (cortical or lacunar) underwent magnetic resonance imaging including diffusion-weighted imaging (DWI). We recorded DWI-positive infarcts and proximity to cortex for small subcortical infarcts. We examined factors associated with C-ID.

Results: 137 patients with a mild cortical or lacunar syndrome had an acute ischemic lesion on DWI. Of these, 21/93 (23%) with a cortical syndrome had an acute lacunar infarct and 7/44 (16%) with a lacunar syndrome had an acute cortical infarct. From 72 patients with an acute lacunar infarct on DWI, lesion proximity to cortex (odds ratio (OR) 14.5, 95% confidence interval (CI) 1.61-130.1), left hemisphere location (OR 8.95, 95% CI 1.23-64.99) and diabetes (OR 17.1, 95% CI 1.49-196.16) predicted C-ID. On multivariate analysis of all 137 patients, C-ID was associated with diabetes (OR 7.12, 95% CI 1.86-27.2).

Conclusions: C-ID occurs in a fifth of patients with mild stroke. Lacunar infarcts lying close to cortex are more likely to cause cortical symptoms. Diabetes is associated with any clinical-imaging mismatch. Stroke misclassification which can arise with clinical classification alone should be minimized in research by verification with high-sensitivity imaging.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Disease
  • Aged
  • Aged, 80 and over
  • Basal Ganglia / blood supply
  • Basal Ganglia / diagnostic imaging
  • Brain Infarction / classification*
  • Brain Infarction / complications
  • Brain Infarction / diagnosis
  • Brain Infarction / diagnostic imaging
  • Brain Ischemia / diagnosis*
  • Brain Ischemia / diagnostic imaging
  • Brain Stem / blood supply
  • Brain Stem / diagnostic imaging
  • Cerebral Cortex / blood supply
  • Cerebral Cortex / diagnostic imaging
  • Cerebral Infarction / diagnosis
  • Cerebral Infarction / diagnostic imaging
  • Diabetes Complications / diagnosis
  • Diabetes Complications / diagnostic imaging
  • Diagnosis, Differential
  • Diagnostic Errors*
  • Diffusion Magnetic Resonance Imaging*
  • Female
  • Humans
  • Infarction, Anterior Cerebral Artery / diagnosis
  • Infarction, Anterior Cerebral Artery / diagnostic imaging
  • Infarction, Posterior Cerebral Artery / diagnosis
  • Infarction, Posterior Cerebral Artery / diagnostic imaging
  • Male
  • Middle Aged
  • Movement Disorders / etiology
  • Prospective Studies
  • Sensation Disorders / etiology
  • Sensitivity and Specificity
  • Single-Blind Method
  • Tomography, X-Ray Computed